Breast Deformity Revisional Surgery
Breast Deformity Revisional Surgery
Capsular contracture is a condition when the capsule around breast implants get very stiff and tight. Symptoms of this range from mild cases where your breasts feel firm and hard, look normal and natural, and does not hurt or bother you, to conditions where the breasts are painful at rest and to the touch, looks grossly disfigured and abnormal. When foreign objects are placed into our bodies, it is normal and natural for our body to form a capsule of fibrous scar tissue around this foreign, non-biological, object. This capsule can be thought of as a shell that the body forms to isolate and separate the implant from the rest of your body. A majority of the time, capsules do not cause a problem. After breast augmentation or reconstruction surgeries, patients are advised to massage the implants to keep the capsule around the implant large so that the implant has some room to move around and remain soft to the touch. After the capsule matures, massage is no longer necessary. Prior to the capsule maturing, massaging can help shape the size and formation of the capsule.
When the implant capsule thickens and gets very stiff and tight, it not only squeezes the implant, but it also looks abnormal. Breasts with severe capsular contracture often look like funny looking balls stuck to your chest wall and may be very painful.
The severity and degree of capsular contractures are graded based on the Baker’s Scale for Capsular Contracture. It is as follows:
Grade I – the breast is normally soft and appears natural in size and shape
Grade II – the breast is a little firm, but appears normal
Grade III – the breast is firm and appears abnormal
Grade IV – the breast is hard, painful to the touch, and appears abnormal
What causes capsule to become pathological? Capsule formation is part of the normal healing process after surgery and foreign body implantation. Many different factors cause this healing process to become abnormal and cause problems. These are potential factors, though not all etiologies have been elucidated.
- Surgical Technique
- Implant rupture
- Sub-acute bacterial infection
- Post-operative hematoma/bleeding
- Genetic pre-disposition to hypertrophic/keloid scar formation
While these factors are suspected and in no means an all-inclusive list, it gives you an idea of potential reasons for developing capsular contractures.
Once a capsular contracture develops, Treatment depends on the severity of your capsular contracture. If you implants are only mildly firm, you may be ok with the mild stiffness and nothing needs to be done. If the stiffness bothers you, the capsule may need to be divided and released so that is becomes larger and softer. The implants should also be changed out for new implants incase the contracture is due to implant related issues, such as a low-grade bacterial contamination, biofilm formation, or structural implant defects. On the other side of the spectrum, with severe Grade III or Grade IV capsular contractures, the entire capsule may need to be taken out, the implants exchanged, and acelluar dermal matrices (e.g. Stratice, Alldoerm, or FlexHD) placed as an internal bra to help prevent future or recurrent capsular contracture.
Other than replacing the implants, alternative therapies include removing your implants and the associated capsule, allowing your breast to heal, and performing a autologous fat grafting to rebuild your breasts. This option is only possible if you have sufficient fat to donate towards making the size of breast you would like. Other autologous options include pedicled flaps (e.g. TRAM, or Latisimus Dorsi Flap) or free tissue transfers (e.g. DIEP, SGAP, IGAP).
After both breast augmentations and breast reconstructions, a common problem many women have is that the implants bottom out. When this happens, the distance between your nipple and your inframammary fold, where you bra underwire sits, gets stretched out. Your nipples look like they are riding high or look like they are pointing up instead of straight ahead. The inferior pole of your breast is bulging downward from the weight of your implants. Your implants have essentially moved downward from their normal position behind/underneath your breast.
Bottoming out deformities occur because there is insufficient support at the inframammary fold from either poor tissue quality or excessively heavy implants. Sometimes it is because the inframammary fold is compromised from your breast reconstruction or augmentation procedure.
Patients that have bottoming out issues need Revisional surgery. Breast implants need to be moved back underneath your breast tissue. If your breast capsule has shrunken superiorly and is keeping your breast from moving back up to a normal position, capsulotomies may have to be performed to release the mature capsule and allow the implant to move back to a normal position.
Once the implant is relocated back to a normal position, the inframammary fold or inferior pole breast tissue needs to be re-enforced to support the weight of the implant without a bottoming out problem reoccurring. Each patient’s situation is a little different and this re-enforcement needs to be tailored to each patient’s condition. Some patients may need extra sutures along the inframammary fold to give the tissue and implants extra support. Sometime sutures are insufficient to re-create or re-enforce the inframammary fold. In these situations, acellular dermal matrices (e.g. Alloderm, Stratice, or FlexHD) or Seri Mesh may need to be utilized to provide the additional implant support necessary. A wide range of options is available for these types of revisional surgeries and the best option depends on each patient’s specific situation.
“Jumping Breast” phenomenon occurs when your breasts jump whenever you use your arms or flex your chest muscles. When patient’s flex, the breasts move up towards the clavicle and neck. When the pectoralis major muscle relaxes, the implants fall down to their normal position again. It is not normal or desirable for implants to move up and down like that. It can even be embarrassing in certain social events.
Patients may suffer from “Jumping Breast” phenomenon when they either have had breast reconstruction or augmentation and the breast implants are placed underneath the pectoralis major muscle. Anatomically, what is happening is that the inferior edge of the pectoralis muscle is pulling the breast implants up when it contracts. This happens in the following situations: 1. The pectoralis muscle is incompletely released inferiorly along its lower border, near the inframammary fold. 2. Scar tissue have formed between the inferior border of the pectoralis major muscle and the chest wall, so then the muscle contracts, it pulls on the scar tissue/implant capsule and this pushes the implants up when the muscle contracts 3.The muscle is incompletely released medially along its attachments to the sternum.
IF YOU SUFFER FROM “JUMPING BREASTS”, REVISIONAL SURGERY IS NECESSARY TO CORRECT THIS.
If your breasts are of a sufficient size and able to mask sub-glandular or sub-fascial implants, your implants can be relocated so that they sit over the pectoralis muscle. The pectoralis muscle would need to be reattached to the chest wall. For many patients, and especially breast reconstruction patients, this is not a good option. If you fall into this category the pectoralis major muscle needs to be released from its attachments inferiorly and along the sternum. Adherent scar tissue needs to be released so that they do not pull up on your implants. Depending on your original surgery, you may need acellular dermal matrices (ADM) to be placed along the inferior pole of your breasts to protect your implants and to provide sufficient inferior pole laxity so that the pectoralis major muscle isn’t able to pull on the implants.
HIGH RIDINGBREAST IMPLANTS
Many patients develop high riding breasts where the implants are very prominent along the superior pole of their breasts. This provides upper pole fullness, which some patients may desire or seek. However, this type of breast is very unnatural and fake looking. High riding breast implants may be associated with breast tissues that are falling off the implants. When this happens, the outline of the breast implants can be seen, and your breast tissue can be seen sagging off the implants with the nipples pointing down towards your feet.
For patients whose implants are riding high and the breast tissue is not “falling off” the implant, nothing needs to be done if you like this look. This becomes a personal preference issue.
Many women prefer the more natural look where it is not obvious that you have breast implants. In these situations, surgery is necessary to release the breast capsule and also the adherent scar tissue. It may also be necessary to release the pectoralis major muscle so that it doesn’t keep the implants artificially high and allow them to drop down into a more natural teardrop position.
When the implants are both riding high and the breast tissue is falling off the implant, a combination surgery is necessary to give you natural looking breasts. As with implants that are riding high without the breast tissue coming off the implants, the implant needs to be released so that it can settle down into a more natural position, as described above. In addition to this, the breast tissue also needs to be lifted up and positioned over the breast implants in a natural anatomical position. Depending on the shape, size, and position of your native breast tissue, the maneuvers and degree of lift necessary to shape your native tissue will vary. After this procedure, your native breast tissue will be relocated to its correct anatomical position with support so that they won’t sag and fall off the implants again. If your tissues are really weak, an internal bra may need to be created using acellular dermal matrices so that it will support the weight of your implants and not bottom out when the implants are released and no longer riding high.
The so called “Double Bubble” deformity that occurs with having implants underneath your breast tissue happens when you have a crease or indentation above and parallel to your infra-mammary fold. This crease or indentation is actually on your breast, along the inferior pole. The breast tissue between these two lines (the artificial indentation and your inframammary fold, bulges out, as does your inferior pole breast tissue above the indentation or crease. The combination of two bulging parallel areas along the inferior pole of the breast gives the appearance of two bubbles sitting on top each other. Hence, the term “double bubble” deformity came to be.
This type of deformity results from your implant sitting below your original native inframammary fold. Some surgeons lower the inframammary fold and the remnant of the old fold is still tethering your breast tissue. Another situation is where the implant dissected below the level of your inframammary fold and created a situation where your natural fold is sitting on top of the implant.
Depending on the desired position of your inframammary fold given your current breast size and desired implant location, correction of this deformity will vary. If the implant is in an abnormally low position, the implant will need to be lifted up to a more natural position and the inframammary fold reinforced so that this does not happen again. If it is desirable for the implant to ride low and it is in the ideal position for your breast size and shape, then the indentations on your breast from your previous inframammary fold will need to be released. Your breast tissue and the supporting ligaments have memory and still remember the fold. These attachments need to be released so your breast tissue can fill out and smooth out. Again, each person may have a slightly different situation and the surgery will be tailored to each person’s situation and condition.
Following implant based breast reconstruction or breast augmentation, some patients suffer from implants that want to fall into their axilla. This occurs when the lateral aspect of the breast implant pocket lacks sufficient soft tissue support or the implant pocket extends into the axilla. While some patients simply push the implants back into place, but having to do so on a chronic basis can get irritating, uncomfortable, or embarrassing.
Instead of suffering with this problem, there is a simple surgical solution. The lateral breast implant pocket either needs a capsulorraphy, where an overly large implant pocket needs to be reduced in size so that it no longer extends laterally into the axilla, or the lateral breast pocket needs to be reinforced with acellular dermal matrices to define the lateral aspect of the breast and make it look natural. A common mistake with inexperienced surgeons is to neglect this lateral aspect of the breast implant pocket or to weaken it too much so that it lacks the necessary support for your breast implant.
When your scapula bone, behind your shoulders in your upper back, lifts up and protrudes from your back, it is describes as a Winged Scapula deformity. This occurs with paralysis or anterior detachment of the seratus anterior muscle, which inserts on the under surface of the scapula bone. This muscle pulls on the scapula and keeps it protruding from your body like a “wing”.
During mastectomy procedures, injury to the long thoracic nerve or the muscle will cause the scapula bone to protrude since in no longer has a tethering muscle to keep it close to the body, resulting in a winging deformity. Early generation techniques for breast reconstruction utilized the seratus anterior as muscle flap coverage for the lateral aspect of the breast implant to protect it. Sometime raising this flap weakens the anterior attachment of this muscle so that it no longer has the strength to pull and tether in the scapula bone. Muscles work on a traction – counter traction principle.
With newer generation implant breast reconstruction techniques involving acellular dermal matrices, these problems have become virtually non-existant, unless the nerve to the seratus anterior mucle has somehow become injured and the muscle is paralyzed. It is no longer necessary to detach the anterior portions of the serratus muscle as a lateral flap to cover a reconstruction implant.
Patients with a winged scapula deformity need a revisional reconstruction using acellular dermal matrices and for the serratus anterior muscle to be freed up and reattached to the lateral thoracic wall. This procedure usually corrects the problem.
You may have had the perfect reconstruction, but due to poor breast tissue quality, it looks like your breast tissue is falling off your implants. The implants haven’t moved and are exactly where they should be, but your breast tissue have drooped and become ptotic.
When your breast tissue is falling off the implant a breast lift is necessary to give you natural looking breasts. Your breast tissue also needs to be lifted up and positioned over the breast implants in a natural anatomical position. Depending on the shape, size, and position of your native breast tissue, the maneuvers and degree of lift necessary to shape your native tissue will vary. After this procedure, your native breast tissue will be relocated to its correct anatomical position with support so that they won’t sag and fall off the implants again. If your tissues are really weak, an internal bra may need to be created using acellular dermal matrices or a Seri scaffold so that it will support the weight of your implants or to provide your breast tissue additional support so that it doesn’t sag off your implants again.
As with all surgeries, not all results are perfect. As plastic surgeons, we strive to achieve symmetrical and aesthetic results. Sometimes this is beyond our control, especially when patients have had differential treatments in each breast. For example, patients may have more breast and axillary tissue removed from one side compared to the other by their breast surgeon. The cancer may be more advanced or involved on one side compared to the other. Patients may receive post-operative radiation on one side and not the other. When this happens, the radiated side will tighten and shrink up compared to the non-radiated side. Correction of these type of asymmetries depends on the problem and surgical planning is tailored to each patient’s situation and condition.
As with all surgeries, not all results are perfect. As plastic surgeons, we strive to achieve symmetrical and aesthetic results. Sometimes this is beyond our control, especially when patients have had differential treatments in each breast. For example, patients may have more breast and axillary tissue removed from one side compared to the other by their breast surgeon. The cancer may be more advanced or involved on one side compared to the other. Sometimes skin flaps following the mastectomy are of differing thickness or may contain lumpy bumpy irregularities. Whatever the issue, procedures can be designed to address and correct the problem. It may involve a simple solution such as liposuctioning fat from another part of the body to fat graft the breasts and eliminate any contour irregularities. More involved procedures may involve the use of acellular dermal matrices to proven scar indentations or tethering or give the breast a better overall shape. These procedures are tailored to each individual patient’s needs.
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